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Introduction
Depression has known associations with musculoskeletal
pain, and outcomes after orthopedic surgery may be negatively affected by this common condition.1,11 Patients with
mood disorders have been shown to require 3 times more
narcotics postoperatively compared with those without
mood disorders; these patients also are at greater risk to
have continued pain beyond 90 days after surgery and have
higher visual analog scale for pain (VAS) scores at greater
than 1 year after surgery.11 Depression has also been associated with greater postoperative pain and narcotic requirement after total joint replacement.14-18,20 and musculoskeletal
trauma.5 Increasing grade of hallux valgus is associated
with worse quality-of-life functional scores10 as well as
higher levels of depression as measured on the Beck
Depression Inventory questionnaire.11 The relationship of
depression with patient outcomes and satisfaction after surgical correction of hallux valgus is not well-studied.
The purpose of this study was to evaluate our cohort of
patients with hallux valgus treated surgically and determine
whether patients with depressive symptoms experienced
different pain and satisfaction levels than those patients
without this condition. We hypothesized that patients with
depressive symptoms would have greater dysfunction preoperatively and less satisfaction after surgery when compared with those patients without depressive symptoms.

Methods
This is a retrospective study evaluating the prevalence and
effects of depressive symptoms in patients undergoing surgery for hallux valgus; prospective data on satisfaction levels was also obtained. Adult patients who had undergone
surgical treatment for hallux valgus by a single fellowshiptrained foot and ankle orthopedic surgeon within a large
academic orthopedic practice over a 2-year period between
January 2014 and December 2015 were included. Patients
were excluded if they had a previous bunionectomy or if
surgery was performed to treat recurrent hallux valgus or
varus. Basic demographic data were collected, including
age, sex, laterality, and type of surgical bunionectomy.
Additional procedures were also recorded.
Patient-reported outcomes were collected at baseline and
at least 11 months postoperatively with the following tools:
VAS, Short Form-12 (SF-12) mental (MCS) and physical
components (PCS), and Foot and Ankle Ability Measure

Foot & Ankle International 39(7)
(FAAM) with Activities of Daily Living (ADL) and Sports
subscales. Personal history of depression and current medications were recorded on the standard intake forms for new
patients. All patients were called to administer a satisfaction
survey at least 11 months after surgery. The survey questions included whether the patient was satisfied in general
after surgery and whether the patient was satisfied with the
current pain level. Satisfaction was scored on a 6-point
scale, with 0 indicating complete dissatisfaction and 6 indicating complete satisfaction.
Bunion severity was categorized based on the type of
procedure performed. The primary surgeon had different
indications with regard to each bunionectomy procedure.
Patients with a 1-2 intermetatarsal angle (IMA) less than 9
degrees but a hallux valgus first metatarsal-phalangeal
angle (HVA) of more than 15 degrees underwent a modified
McBride procedure or Silver ostectomy. Patients with a 1-2
IMA greater than 9, but less than 14 degrees, underwent a
Chevron distal first metatarsal osteotomy, and those with
hallux valgus interphalangeus underwent an Akin proximal
phalangeal hallux osteotomy. For this study, these deformities were all considered to be mild. Patients with a 1-2 IMA
of 14 degrees or greater, without evidence of hypermobility
of the first tarsometatarsal (TMT) joint and without arthritis
involving the first metatarsophalangeal (MTP) joint underwent a Ludloff or proximal opening wedge osteotomy and
were considered to have a moderate deformity. Patients
with clinical and radiographic evidence of first TMT hypermobility and a 1-2 IMA of 14 degrees or greater underwent
Lapidus tarsometatarsal arthrodesis with or without calcaneal bone graft. Those with severe arthritic changes involving the first MTP joint and a hallux valgus deformity (all
had an HVA of greater than 35 degrees) underwent a first
MTP joint arthrodesis and were excluded from the study.
Database review was performed, and 275 patients were
identified. Thirty-six patients were excluded because they
had surgery for recurrent hallux valgus or varus, leaving
239 patients available for analysis. The average patient age
was 51.6 years, and there were 207 women (87%). Twohundred eighteen patients (91%) completed preoperative
functional scores, 160 patients (67%) were reached by
phone for a satisfaction survey, and 154 patients (64%)
completed postoperative functional scores at an average of
23 months and 21 months, respectively. Sixty-seven patients
(28%) had a Chevron, Modified McBride, Aikin, or Silver
procedure; 139 (58%) had a Ludloff procedure; and 32
(13%) had a Lapidus procedure. Additional procedures

Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
Sidney Kimmel Medical College at Thomas Jefferson University, Ivyland, PA, USA

Corresponding Author:
Steven M. Raikin, MD, Rothman Institute, 925 Chestnut St, Philadelphia, PA 19107, USA.
Email: steven.raikin@rothmaninstitute.com

Table of Contents for the Digital Edition of Foot & Ankle International - July 2018